What 630 million professional claims reveal about where provider revenue actually leaks
Revenue leakage is more than a denial problem. Across denials, underpayments and recovery, money leaves the system in ways standard reporting never surfaces, including on claims that were accepted, adjudicated and paid. Here’s where it goes, and where you can stop it.
Finding #1: Denials stay high
Our analysis put the average denial rate at 14.6% across all payers — nearly three times the 5% benchmark — with Medicaid products spiking to 20–23%.
FInding #2: Paid isn't paid in full
Even adjudicated, “paid” claims leak revenue. Underpayments hit 4.9% of claims and pay 27% below the allowed amount when they occur — and most teams can’t see it by payer.
Finding #3: Recovery misses the risk
Recovery rarely tracks where the risk is. Across payers it averages about 29%, leaving roughly 70% of contested revenue on the table — and its weakest for Medicaid, which carries the highest denial burden.
Finding #4: Most denials are preventable
More than half of top denials come from process and accuracy gaps, not clinical findings — and over 66% start in the front-end and mid-cycle, before a claim ever leaves your organization.
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Data methodology
Based on Cognizant’s TriZetto® Advanced Reimbursement Manager (ARM) platform, linking 837 claim files to corresponding 835 remittance data at scale.
The analysis evaluates denial patterns, payment accuracy, recovery performance and payer behavior using real adjudicated claim outcomes, not estimates or surveys.
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